A 70-year-old client in a nursing home is found wandering in the hall and has a new onset confusion. Which action should the registered nurse implement ́ first?
Notify the client's family to come visit client
Instruct the client return to their room
Ask the unlicensed assistive personnel (UAP) to push fluids
Assess the client's lung fields and temperature
The Correct Answer is D
A. Notifying the client's family may be appropriate after assessing the client and identifying the cause of the confusion. However, it is not the first action, as the priority is to determine if the confusion is due to a medical condition requiring immediate attention.
B. Instructing the client to return to their room addresses the wandering behavior but does not address the underlying cause of the new onset confusion. Without further assessment, this action may delay necessary interventions.
C. Asking the UAP to push fluids assumes that dehydration is the cause of the confusion without evidence. While encouraging hydration may be beneficial later, it is essential first to assess for other potential causes, such as infection or hypoxia.
D. Assessing the client's lung fields and temperature is the first priority because new onset confusion in an older adult is often a symptom of an underlying medical issue, such as infection (e.g., pneumonia or urinary tract infection) or hypoxia. Early assessment helps identify the cause and guide appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Storing oxygen tanks near sources of heat is dangerous. Oxygen should be stored in a cool, dry place away from heat sources and flammable materials to prevent the risk of fire or explosion.
B. Oxygen therapy should not be limited to periods of activity or exertion. For patients with COPD, continuous oxygen therapy is often necessary to maintain adequate oxygen saturation levels, even during sleep.
C. Adjusting the oxygen flow rate to the highest level can be harmful, especially in patients with COPD, as it may suppress their hypoxic drive to breathe. The flow rate should be prescribed and adjusted by the healthcare provider.
D. Continuous use of oxygen therapy, even during sleep, is essential for maintaining adequate oxygen saturation levels in patients with COPD. This helps prevent hypoxemia and ensures the patient receives the necessary oxygen support.
Correct Answer is C
Explanation
A. Inhaling and exhaling quickly through pursed lips does not achieve the intended purpose of pursed-lip breathing. This technique is designed to promote slower, controlled breathing to prevent airway collapse and improve oxygen exchange.
B. Exhaling quickly through pursed lips negates the benefits of pursed-lip breathing. The purpose of this technique is to prolong exhalation, reducing air trapping and improving ventilation.
C. Inhaling deeply through the nose and exhaling slowly through pursed lips is the correct technique for pursed-lip breathing. This method helps maintain open airways, reduces dyspnea, and promotes relaxation.
D. Inhaling deeply through pursed lips and exhaling quickly through the nose is not consistent with proper pursed-lip breathing. The inhalation should be through the nose, and exhalation should be slow and controlled through pursed lips.
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